How to manage a patient with hyperglycemia, vomiting, and diarrhea, presenting with slightly hypertensive vital signs?

Management of Hyperglycemia with Vomiting and Diarrhea

This patient requires immediate assessment for diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), aggressive fluid resuscitation with isotonic saline, and consideration of sick day medication adjustments—particularly temporary discontinuation of SGLT2 inhibitors, ACE inhibitors/ARBs, and diuretics if the patient is taking them. 1

Immediate Assessment and Triage

Contact the healthcare provider immediately because this patient meets criteria for urgent evaluation: vomiting 5 times (exceeds the threshold of >4 episodes in 12 hours) with hyperglycemia (glucose 220 mg/dL) and inability to maintain adequate fluid intake. 1

Critical Laboratory Evaluation Needed

Obtain the following STAT to differentiate between DKA, HHS, or simple hyperglycemia with dehydration: 1, 2

• Plasma glucose, venous blood gas (pH), serum bicarbonate, and ketones (blood or urine)
• Serum electrolytes with calculated anion gap, blood urea nitrogen, creatinine
• Corrected sodium (add 1.6 mEq for each 100 mg/dL glucose >100 mg/dL) 1, 3
• Complete blood count, urinalysis, and electrocardiogram 1

Key Diagnostic Thresholds

• DKA criteria: Blood glucose >250 mg/dL, venous pH <7.3, bicarbonate <15 mEq/L, moderate ketonuria/ketonemia 1
• HHS criteria: Blood glucose >600 mg/dL, venous pH >7.3, bicarbonate >15 mEq/L, effective serum osmolality ≥320 mOsm/kg 3
• This patient's glucose of 220 mg/dL suggests either early DKA, sick day hyperglycemia with dehydration, or inadequate diabetes control during acute illness 1

Immediate Fluid Resuscitation

Begin isotonic saline (0.9% NaCl) at 15-20 mL/kg/h during the first hour to restore circulatory volume and tissue perfusion, regardless of whether this is DKA, HHS, or simple dehydration. 1, 2, 3 This translates to approximately 1-1.5 liters in the first hour for an average adult.

• Aggressive early fluid administration improves outcomes and speeds recovery in hyperglycemic emergencies 4
• Monitor fluid input/output, blood pressure, heart rate, and clinical examination to assess hydration progress 5, 3

Sick Day Medication Management

Immediately instruct the patient to temporarily stop the following medications if they are taking them: 1

• SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) - 96% consensus recommendation
• ACE inhibitors/ARBs (lisinopril, losartan, etc.) - 90% consensus
• Diuretics (furosemide, hydrochlorothiazide, spironolactone) - 95% consensus
• NSAIDs - 95% consensus

Insulin and Hypoglycemic Agent Adjustments

• For patients on insulin: Do not stop insulin entirely, but may need dose reduction based on oral intake 1
• For patients on sulfonylureas or meglitinides: Hold if blood glucose is low; if already taken today, instruct patient to eat to prevent hypoglycemia (effect lasts 12-24 hours) 1
• Check blood glucose every 4-6 hours while symptomatic 1
• Check ketones if patient is on SGLT2 inhibitors, insulin, or ketogenic diet 1

Electrolyte Management Priorities

Potassium Monitoring is Critical

Never start insulin before excluding hypokalemia (K+ <3.3 mEq/L) as insulin drives potassium intracellularly and can precipitate life-threatening cardiac arrhythmias. 1, 3, 6

• Once renal function is confirmed and K+ is known, add 20-40 mEq/L potassium to IV fluids when serum K+ falls below 5.5 mEq/L 1, 5, 3
• Total body potassium deficits are common despite potentially normal initial levels due to acidosis and dehydration 5
• Monitor potassium closely with IV insulin due to rapid onset of action and risk of hypokalemia causing respiratory paralysis or ventricular arrhythmia 6

Insulin Therapy Considerations

If DKA is confirmed (pH <7.3, ketones present): 1, 2

• After excluding hypokalemia, give IV bolus of regular insulin 0.15 U/kg, followed by continuous infusion at 0.1 U/kg/h
• Target glucose decline of 50-75 mg/dL per hour 1, 2
• When glucose reaches 250-300 mg/dL, add dextrose 5-10% to IV fluids and reduce insulin to 0.05-0.1 U/kg/h 2

If simple hyperglycemia without DKA: 1

• The main goal is avoiding hypoglycemia while allowing glucose in upper target range during acute illness
• Adjust home regimen based on oral intake and symptom severity

Monitoring During Treatment

Draw blood every 2-4 hours for serum electrolytes, glucose, blood urea nitrogen, creatinine, and osmolality (if HHS suspected). 1, 5, 3

• Venous pH is adequate for monitoring; repeat arterial blood gases are generally unnecessary 1, 3
• Monitor for complications including cerebral edema (especially if correcting osmolality too rapidly), cardiac arrhythmias from electrolyte shifts, and hypoglycemia from insulin 3, 6

Critical Pitfalls to Avoid

• Do not correct hyperglycemia or osmolality too rapidly: Change in serum osmolality should not exceed 3 mOsm/kg/h to prevent cerebral edema 3
• Do not administer bicarbonate: It does not improve outcomes in DKA or HHS regardless of pH 5, 2, 3
• Do not overlook underlying precipitants: Obtain cultures (urine, blood) and treat infection if suspected with appropriate antibiotics 1, 2, 3
• Do not stop all diabetes medications in type 1 diabetes: Even with poor oral intake, small amounts of basal insulin prevent acute hyperglycemic complications 1

Disposition and Follow-up

• If symptoms do not resolve within 72 hours or patient cannot maintain fluid intake, escalate care 1
• Seek emergency care immediately for reduced consciousness, confusion, difficulty breathing, or inability to keep fluids down 1
• Once stabilized, ensure structured discharge planning with diabetes education and follow-up scheduled prior to discharge 5, 2